Provider Demographics
NPI:1528566643
Name:AUGUSTIN, FAVIOLA (LCSW)
Entity Type:Individual
Prefix:
First Name:FAVIOLA
Middle Name:
Last Name:AUGUSTIN
Suffix:
Gender:F
Credentials:LCSW
Other - Prefix:
Other - First Name:FAVIOLA
Other - Middle Name:
Other - Last Name:AUGUSTIN
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LCSW
Mailing Address - Street 1:3690 S PARK AVE STE 805
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85713-5042
Mailing Address - Country:US
Mailing Address - Phone:520-616-6760
Mailing Address - Fax:520-616-6799
Practice Address - Street 1:3690 S PARK AVE STE 805
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85713-5042
Practice Address - Country:US
Practice Address - Phone:520-616-6760
Practice Address - Fax:520-616-6799
Is Sole Proprietor?:No
Enumeration Date:2018-01-23
Last Update Date:2021-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZLCSW-170051041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ349583Medicaid